Why don't general dental practitioners test for diabetes in periodontitis patients? How infrastructure, role identity and self-efficacy can prevent effective shared care.

Aim To explore the attitudes of general dental practitioners (GDPs) towards testing for diabetes in periodontitis patients amid recommendations from professional organisations that dentists and oral health professionals are well-positioned to support the diagnosis of diabetes in primary dental care.Method GDPs were selected based on purposeful sampling. The number of GDPs recruited was dependent on thematic saturation. Semi-structured telephone interviews were conducted with all recruited GDPs. Interviews were audio recorded and transcribed verbatim. Thematic analysis was utilised to generate initial codes and subsequent themes.Results Fifteen GDPs participated in this qualitative study. Three main interrelated themes emerged: 1) there is an inadequate infrastructure within the current NHS; 2) the difference in the definition and threshold of the social and professional roles and identities of GDPs; and 3) there is a low self-efficacy to testing due to a perceived lack of knowledge.Conclusions This qualitative study has identified the barriers to and enablers for testing for diabetes in patients with periodontitis attending general dental practices in England. The findings have the potential to influence interventions and policies going forward to improve the co-management of diabetes and periodontitis within primary healthcare.

A multi-centre early evaluation of the effectiveness of workshop teaching to improve the confidence of UK and Irish dental students when addressing patient mental health.

Background Dental practitioners can have low confidence when addressing patient mental health as part of wider patient management. This is increasingly relevant due to the rising prevalence of mental health conditions and the relationship that can exist between mental and oral health. Interactive workshop teaching on patient mental health may enhance the confidence of dental students when addressing mental health conditions in patients. This study trialled workshop teaching as an educational intervention in five UK and Irish dental schools.Methods A quantitative, scenario-based confidence survey to further establish the need for intervention, followed by delivery of a workshop intervention to volunteer participants. Pre- and post-workshop surveys were used to assess the effectiveness of the workshop.Results Survey data showed low confidence among dental students when addressing patient mental health. Workshop intervention improved dental student confidence on average from 2.3-3.7 on a five-point scale, with less than 0.5% likelihood that reported changes in confidence were due to chance.Discussion Low confidence of dental students addressing patient mental health scenarios echoed wider literature findings surrounding dental clinicians' ability to address patient mental health. This further demonstrated the need for educational intervention, with workshop effectiveness demonstrated within this paper.Conclusion Workshop teaching is an effective way to enhance dental student confidence when addressing patient mental health and should be considered for implementation in the Bachelor of Dental Surgery curriculum.

How confidently do students address patients with psychiatric conditions in the dental clinic? A service evaluation in a UK dental school.

Background Extensive literature covers the relationship between psychiatric and dental health, but little research explores the ability of dental practitioners to confidently address patient mental health. This paper explored self-reported confidence of dental students when addressing patient mental health in a university setting.Methods Mixed-method approach involving a quantitative scenario-based survey and focus groups. Research participants were from years three, four and five of the Bachelor of Dental Surgery (BDS) degree.Results Survey data showed low confidence among dental students. Focus group themes included lack of education, prejudice and rejecting responsibility. Participants suggested communication skills workshops to help improve confidence.Discussion Self-reported confidence among dental students when addressing patient mental health was low, echoing wider literature findings. Focus groups highlighted an absence of patient mental health from the curriculum. Systematic reviews have recommended greater education around screening tools for 'assessing psychological comorbidity'. Using best practice, focus group data and psychologist guidance, we developed a communication skills case-based workshop for service improvement.Conclusion Low student confidence likely originates from limited focus within the BDS curriculum. The research will be expanded into other UK dental schools to explore the confidence of dental students nationally and to evaluate and trial the developed workshop.

Practice, complexity and evidence-based practice.

In this opinion piece, I explore practice and complexity, the latter a term often used in relation to the field of special care dentistry. As research is usually concerned with generating new knowledge of some sort, I explore how knowledge is viewed from a practice perspective, as shared, transitory and situated in interactions, rather than being a thing possessed. This leads into a discussion of how the word complexity has been viewed in complexity science, contrasting it with the linear models generated in the evidence-based practice realm from research and research-informed guidelines. Finally, I address the inherent paradox of attempting to align linear models generated from research with the complexity of practice. I suggest that to evaluate and improve practices we should use narrative and exploratory methods that allow its complexity to be made sense of, made transparent and made available for interpretation.

Knowing in general dental practice: Anticipation, constraint, and collective bricolage.

RATIONALE, AIMS, AND OBJECTIVES: Much of the literature concerned with health care practice tends to focus on a decision-making model in which knowledge sits within the minds and bodies of health care workers. Practice theories de-centre knowledge from human actors, instead situating knowing in the interactions between all human and non-human actors. The purpose of this study was to explore how practice arises in the moment-to-moment interactions between general dental practitioners (GDPs), patients, nurses, and things. METHOD: Eight GDPs in two dental practices, their respective nurses, 23 patients, and material things were video-recorded as they interacted within clinical encounters. Videos were analysed using a performative approach. Several analytic methods were used: coding of interactions in-video; pencil drawings with transcripts; and dynamic transcription. These were used pragmatically and in combination. Detailed reflective notes were recorded at all stages of the analysis, and, as new insights developed, theory was sought to help inform these. RESULTS: We theorized that knowing in dental practice arises as actors translate embodied knowing through sayings and doings that anticipate but cannot predict responses, that knowing is constrained by the interactions of the practice but that the interactions at the same time are a collective bricolage-using the actors' respective embodied knowing to generate and solve problems together. CONCLUSION: Practices are ongoing ecological accomplishments to which people and things skilfully contribute through translation of their respective embodied knowing of multiple practices. Based on this, we argue that practices are more likely to improve if people and things embody practices of improvement.

Diagnostic efficacy of direct and indirect digital imaging for approximal caries.

Data sourcesMedline, Embase, LILACS, PubMed, The Cochrane Library and Web of Science databases. A grey literature search was conducted through Google Scholar, where abstracts from the top 100 results (as sorted by search engine relevance) were examined. Hand searching of reference lists only. No language restrictions were imposed.Study selectionStudies that evaluated the efficacy of bitewing and periapical images produced by photostimulable phosphor plate (PSP) and direct digital sensor (DDS) systems for the diagnosis of approximal dental caries in extracted human teeth. Studies were required to have used histologic analysis as the gold standard comparison. Primary outcomes were sensitivity and specificity regarding detection of dental caries.Data extraction and synthesisTwo reviewers independently evaluated the titles and abstracts of studies identified through the search, selecting articles according to established inclusion criteria. The selected articles were subsequently reviewed full-text by the same two authors. Disagreements regarding article inclusion were resolved by consensus with an additional third reviewer. One reviewer performed initial data extraction using a customised data extraction form based on the PICOS principle, with two other authors independently verifying collected information. Risk of bias was assessed independently by three reviewers using the QUADAS-2 checklist. A meta-analysis was performed on the grouped studies that presented suitably homogeneous data to evaluate diagnostic capability for approximal caries in dentine. Results were presented with 95% confidence intervals.ResultsSix studies were included, with four being used for meta-analysis. Methodologies of all studies were considered low risk of bias. Only one study reported a significant difference between PSP and DDS technologies; remaining studies determined that PSP and DDS were comparable in the clinical detection of caries. The meta-analysis sample total was 668 tooth surfaces. All studies reported poor sensitivity and high specificity. For PSP, sensitivity ranged from 15 to 54%, and specificity from 84 to 100%. For DDS, sensitivity varied from 16 to 56%, and specificity from 90 to 100%.ConclusionsDDS and PSP systems are excellent at identifying caries-free surfaces, but both lack sufficient sensitivity to reliably identify surfaces with caries. There is no significant difference between performances of DDS and PSP digital systems for caries detection.

Customised fixed appliance systems and treatment duration.

DesignRandomised controlled trial.InterventionPatients aged 12-30 years requiring fixed orthodontic treatment were eligible and were randomly allocated to treatment with the Insignia customised orthodontic system or the Damon Q noncustomised orthodontic system.Outcome measureThe primary outcome measure was treatment duration. Secondary outcomes were quality of treatment result; the degree of improvement graded using the Peer Assessment Rating (PAR) score; number of visits from the first visit after bonding to debonding; number of loose brackets; time required for treatment planning; and number of complaints.ResultsOne hundred and eighty patients entered the trial. Four were lost to follow-up and two did not complete treatment, so 174 were analysed. Treatment duration was 1.29 ± 0.35 years in the customised group and 1.24 ± 0.37 years in the noncustomised group. The PAR did not differ significantly between groups. However, the orthodontist had a significant effect on treatment duration, quality of treatment outcome and number of visits (P < 0.05). Compared to the noncustomised group, the customised group had more loose brackets, a longer planning time and more complaints.ConclusionsThe customised orthodontic system was not associated with significantly reduced treatment duration, and treatment quality was comparable between the two systems.

No difference in the long-term clinical performance of direct and indirect inlay/onlay composite restorations in posterior teeth.

Data sourcesMedline, Embase, the Cochrane Oral Health Group's Trials Register and CENTRAL. Unpublished literature was searched on ClinicalTrials.gov, the National Research Register, and Pro-Quest Dissertation Abstracts and Thesis database. Hand searching of reference lists only.Study selectionRandomised controlled trials with a minimum of three years follow-up that compared direct to indirect inlays or onlays in posterior teeth. Primary outcome was failure (the need to replace or repair).Data extraction and synthesisTwo reviewers independently and in duplicate performed the study selection and two extracted data independently using a customised data extraction form. The unit of analysis was the restored tooth. Risk of bias was assessed using the Cochrane Risk of Bias tool. Meta-analysis was conducted on two studies using the random-effects model.ResultsThree studies were included. Across these studies there were 239 participants in whom 424 restorations were placed. Two studies compared direct and indirect inlays and had follow-up of five and 11 years respectively. One study compared direct and indirect onlays with a follow-up of five years. The studies were at unclear or high risk of bias. For direct and indirect inlays, Relative Risk (RR) of failure after five years was 1.54 (95% Cl: 0.42, 5.58; p = 0.52) in one study and, in another was 0.95 (95% Cl: 0.34, 2.63; p = 0.92) over 11 years. For onlays there was also no statistically-significant difference in survival, though overall five-year survival was 87% (95% CI: 81-93%).ConclusionsThere is insufficient evidence to favour the direct or indirect technique for the restoration of posterior teeth with inlays and onlays.

Describing knowledge encounters in healthcare: a mixed studies systematic review and development of a classification.

BACKGROUND: Implementation science seeks to promote the uptake of research and other evidence-based findings into practice, but for healthcare professionals, this is complex as practice draws on, in addition to scientific principles, rules of thumb and a store of practical wisdom acquired from a range of informational and experiential sources. The aims of this review were to identify sources of information and professional experiences encountered by healthcare workers and from this to build a classification system, for use in future observational studies, that describes influences on how healthcare professionals acquire and use information in their clinical practice. METHODS: This was a mixed studies systematic review of observational studies. DATA SOURCES: OVID MEDLINE and Embase and Google Scholar were searched using terms around information, knowledge or evidence and sharing, searching and utilisation combined with terms relating to healthcare groups. ELIGIBILITY: Studies were eligible if one of the intentions was to identify information or experiential encounters by healthcare workers. DATA EXTRACTION: Data was extracted by one author after piloting with another. STUDY APPRAISAL: Studies were assessed using the Mixed Methods Appraisal Tool (MMAT). PRIMARY OUTCOME: The primary outcome extracted was the information source or professional experience encounter. ANALYSIS: Similar encounters were grouped together as single constructs. Our synthesis involved a mixed approach using the top-down logic of the Bliss Bibliographic Classification System (BC2) to generate classification categories and a bottom-up approach to develop descriptive codes (or "facets") for each category, from the data. The generic terms of BC2 were customised by an iterative process of thematic content analysis. Facets were developed by using available theory and keeping in mind the pragmatic end use of the classification. RESULTS: Eighty studies were included from which 178 discreet knowledge encounters were extracted. Six classification categories were developed: what information or experience was encountered; how was the information or experience encountered; what was the mode of encounter; from whom did the information originate or with whom was the experience; how many participants were there; and where did the encounter take place. For each of these categories, relevant descriptive facets were identified. CONCLUSIONS: We have sought to identify and classify all knowledge encounters, and we have developed a faceted description of key categories which will support richer descriptions and interrogations of knowledge encounters in healthcare research.

Little research on effective tools to improve patient safety in the dental setting.

Data sourcesMedline via OVID, Embase via OVID, HMIC via OVID, CINAHL via EBSCO and Web of Science.Study selectionDescriptive, observational and experimental studies that used or described the development of patient safety interventions relating to dental care. Outcomes of interest were: patient safety, harm prevention, risk minimisation, patient satisfaction and patient acceptability, professional acceptability, efficacy, cost-effectiveness and efficiency.Data extraction and synthesisAll titles and abstracts were screened by at least two authors. The eligible studies were data extracted by two authors, with disagreements resolved by a third reviewer if necessary. A narrative approach was taken and quality assessed using CASP tools.ResultsNine studies were identified. Four described the use of checklists, three the use of reporting systems, one the use of electronic reminders and one the use of trigger tools. The risk of bias in the studies was high.ConclusionsThe available literature on patient safety is in its infancy. Surgical checklists may be effective in reducing surgical errors.

Nicotine lozenges and behavioural interventions may help smokeless tobacco users to quit.

DATA SOURCES: Cochrane Central Register of Controlled trials (CENTRAL); Medline; Embase; PsycINFO. Additional sources were also searched for early versions of the review: Web of Science, Dissertation Abstracts Online, Scopus, Healthstar, ERIC, National Technical Information Service database and Current Contents. STUDY SELECTION: Randomised controlled trials and pseudo-randomised controlled trials allocating smokeless tobacco (ST) users to an intervention or control, or to different interventions. Interventions could be pharmacological (ie nicotine replacement therapy (NRT), bupropion, varenicline) or behavioural, and could be directed at individual ST users or at groups of users. DATA EXTRACTION AND SYNTHESIS: Two authors independently extracted data about participants, interventions, outcomes and methodological quality. Any discrepancies in extracted data were resolved by consensus. Synthesis followed standard Cochrane methodology. RESULTS: Thirty-four trials were included, 32 from the USA, one from Sweden and one from Sweden and Norway. Sixteen of the trials assessed pharmacological interventions and 19 assessed behavioural interventions (two studies did both). Varenicline increased ST abstinence rates (risk ratio 1.34, 95% confidence interval (CI) 1.08-1.68). Bupropion did not show a benefit of treatment. Neither nicotine patch nor nicotine gum increased abstinence. Nicotine lozenges did increase tobacco abstinence (RR 1.36, 95% CI 1.17-1.59). Behvaioural interventions resulted in a RR of 1.39 (95% CI 1.25-1.55) for those already motivated to quit and 1.37 (95% CI 1.23-1.53) for anyone. CONCLUSIONS: Varenicline, nicotine lozenges and behavioural interventions may help ST users to quit. Confidence in results for nicotine lozenges is limited. Confidence in the size of effect from behavioural interventions is limited because the components of behavioural interventions that contribute to their impact are not clear.

Evidence unclear on whether Type I or II diabetes increases the risk of implant failure.

DATA SOURCES: PubMed, Web of Science and the Cochrane Oral Health Group Trials Register, www.clinicaltrials.gov, www.centerwatch.com and www.clinicalconnection.com databases. Manual searches of a number of dental journals and the reference lists of identified studies were undertaken. STUDY SELECTION: Human clinical studies comparing implant failure rates in diabetic and non-diabetic patients were considered. Three reviewers independently selected studies. DATA EXTRACTION AND SYNTHESIS: The definition of implant failure used was complete loss of the implant. Study quality was assessed using the Cochrane risk of bias approach. A narrative summary of the studies and meta-analysis are presented. RESULTS: Fourteen studies were included (one randomised controlled trial, six controlled clinical trials and seven retrospective analysis); all 14 were considered to be at high risk of bias. Meta-analysis (14 studies) found no significant difference between diabetic and non-diabetic patients; risk ratio of 1.07 (95% CI = 0.80, 1.44)(p = 65). A meta-analysis of two studies found a statistically significant difference (mean difference =0.20, 95% CI = 0.08, 0.31 p = 001;) between diabetic and non-diabetic patients concerning marginal bone loss, favouring non-diabetic patients. Meta-analysis was not possible for postoperative infections. CONCLUSIONS: The results of the present systematic review should be interpreted with caution because of the presence of uncontrolled confounding factors in the included studies. Within the limits of the existing investigations, the difference between the insertion of dental implants in non-diabetic and diabetic patients did not statistically affect the implant failure rates.

Amalgam or composite fillings--which material lasts longer?

DATA SOURCES: Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase and LILACS. Hand searched relevant journals and attempted contact with authors of unpublished studies and manufacturers. STUDY SELECTION: Randomised controlled trials comparing dental resin composites with dental amalgams in permanent posterior teeth with a minimum follow up of three years were eligible. DATA EXTRACTION AND SYNTHESIS: Data were extracted independently by a minimum of two review authors using specially designed data extraction forms. Risk of bias was assessed using the Cochrane risk of bias tool. Relative risks and 95% CIs were extracted for dichotomous data and mean difference (MD) or standardised mean difference (SMD) for continuous data. Relative risk was combined in a meta-analysis. RESULTS: Seven studies were included. Two were parallel and five split-mouth design. Data from 871 participants were available from the two parallel studies but several of the split-mouth studies did not report the number of participants. All studies were considered at high risk of bias. Only data from the two parallel studies were included in the primary meta-analysis. Failure rates in these studies were recorded for between five and seven years. The risk ratio of failure for composite versus amalgam was 1.89 with 95% CI of 1.52-2.35. The increased failure was primarily due to caries rather than fracture. CONCLUSIONS: There is low-quality evidence to suggest that resin composites lead to higher failure rates and risk of secondary caries than amalgam restorations.

Multifaceted and mixed didactic-interactive methods are more effective ways to learn and change behaviour.

DATA SOURCES: The following electronic databases were searched from 1986 to the present: Cochrane Library (Cochrane Database of Systematic Reviews, DARE and HTA Databases, and Cochrane CENTRAL Register of Controlled Trials), Medline In Process and Other Non-Indexed Citations and Medline (Ovid), Embase (Ovid), ERIC (CSA), Index to Theses (Expert Information Services), and ZETOC (British Library Electronic Table of Contents and conference proceedings). No language restrictions. STUDY SELECTION: Randomised controlled trials or quasi-experimental designs were eligible which evaluated continuing professional development (CPD) interventions in dentistry (for dentists and professions complimentary to dentistry) on learning gains, behaviour change or patient outcomes. These could be compared against no intervention or another CPD intervention. There were no minimum follow up times. DATA EXTRACTION AND SYNTHESIS: The following data were extracted by two reviewers: bibliographic details, settings, characteristics about participants, intervention and control conditions, outcome measures, findings and conclusions. Studies were grouped thematically according to the intervention, and the studies were quality assessed using a custom system based on the CONSORT statement. The results were reported in a narrative form and no attempt was made to combine them in a meta-analysis. RESULTS: Ten studies were included. Eight studies were judged to be of high to moderately high quality. None of the studies measured patient outcomes, but a multifaceted black box intervention resulted in self-reported patient care and face-to-face contact to change antibiotic prescribing habits showed a change in clinician behaviour. The size of this effect for both of these is not reported here. There was some effect on knowledge but not on behaviour for courses and workshops, written material, computer-assisted learning and audit and feedback. CONCLUSIONS: Multi-method and multi-phased dental CPD has potential for the greatest impact on practitioner behaviour.

Audit and feedback had small but potentially important improvements in professional practice.

DATA SOURCES: Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Medline, Ovid; Embase, CINAHL, EBSCO, Science Citation Index and Social Sciences Citation Index, ISIWeb of Science STUDY SELECTION: Randomised trials of audit and feedback that reported objectively measured health professional practice or patient outcomes. DATA EXTRACTION: Data were abstracted by two independent review authors using a data extraction form. The following factors were examined as possible explanations for the variation in the effectiveness of interventions across comparisons; format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient and risk of bias within the trial itself. Risk of bias was assessed using EPOC criteria. The degree of confidence in the estimate of effect across studies was assessed using the GRADE approach. All outcomes were expressed as compliance with desired practice and both professional and patient outcomes were assessed, though separately. RESULTS: One hundred and forty studies were included. Using 70 of these 108 comparisons were made. After excluding studies at high risk of bias there were 82 comparisons from 49 studies with dichotomous outcomes, and the weighted median adjusted RD was 4.3% (interquartile range (IQR) 0.5% to 16%). For studies with continuous outcomes the weighted median adjusted percentage change relative to control was 1.3% (IQR = 1.3%to 28.9%). For patient outcomes the weighted median RD was 0.4% (IQR -1.3% to 1.6%) in studies reporting dichotomous outcomes, and the weighted median percentage change was 17% (IQR 1.5% to 17%) for studies with continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats and when it includes both explicit targets and an action plan. CONCLUSIONS: Audit and feedback generally lead to small but potentially important improvements in professional practice.

Poor quality evidence suggests that failure rates for atraumatic restorative treatment and conventional amalgam are similar.

DATA SOURCES: The Medline, Cochrane CENTRAL, Biomed Central, Database of Open Access Journals (DOAJ), OpenJ-Gate, Bibliografia Brasileira de Odontologia (BBO), LILACS, IndMed, Sabinet, Scielo, Scirus (Medicine), OpenSIGLE and Google Scholar databases were searched. Hand searching was performed for journals not indexed in the databases. References of included trials were checked. STUDY SELECTION: Prospective clinical trials with test and control groups with a follow up of at least one year were included. DATA EXTRACTION AND SYNTHESIS: Data abstraction was conducted independently and clinical and methodologically homogeneous data were pooled using a fixed-effects model. RESULTS: Eighteen trials were included. From these 32 individual dichotomous datasets were extracted and analysed. The majority of the results show no differences between both types of intervention. A high risk of selection-, performance-, detection- and attrition bias was identified. Existing research gaps are mainly due to lack of trials and small sample size. CONCLUSIONS: The current evidence indicates that the failure rate of high-viscosity GIC/ART restorations is not higher than, but similar to that of conventional amalgam fillings after periods longer than one year. These results are in line with the conclusions drawn during the original systematic review. There is a high risk that these results are affected by bias, and thus confirmation by further trials with suitably high numbers of participants is needed.

Quality of reporting randomised controlled trials in major dental journals suboptimal.

DATA SOURCES: Hand searching of the most recent 24 issues of six high impact dental journals. STUDY SELECTION: RCTs involving only humans, from 24 issues of six leading specialty journals, covering a period up to July 2009 were included, including cluster randomised trials. DATA EXTRACTION AND SYNTHESIS: Each article included in the study was assessed and scored independently by two observers, with any discrepancies being resolved by a third observer. In this study the modified CONSORT checklist was used to score each applicable item of data. The sum of the scores was converted to a percentage value for each trial. The data were analysed using descriptive statistics. Data regarding the publishing journal, country of origin of the trial, number of authors, involvement of statistician/epidemiologist, number of centres involved, ethics committee approval were subject to quantitative analysis. RESULTS: Ninety-five RCTs were identified with, according to the authors, generally suboptimal scores on quality reporting on key CONSORT areas. Significant differences in scores were found among the journals covering the named specialties. Overall there was a positive association between the quality score in studies with more authors, multicentre studies and studies in which a statistician/epidemiologist was involved. CONCLUSIONS: The overall quality of reporting RCTs in major dental journals was considered suboptimal in key CONSORT areas. This is very important as the reported results of RCTs can have an impact on future patient care.